Since joining forces six years ago to address important public health needs among military families, the Fort Liberty Public Health Partnership is deploying evidence-based public health protocols – especially in cancer prevention – and has grown its vision for the health and well-being of Army families and nearby communities in Cumberland County in southeast North Carolina.
Home to nearly 10% of the Army’s active forces, Fort Liberty in Fayetteville is the largest U.S. Army installation by population and one of the largest installations in the world. More than 65% of Fort Liberty soldiers live off-base in eight surrounding counties.
The partnership includes the Fort Liberty Department of Public Health, the Cumberland County Department of Public Health, UNC Lineberger Comprehensive Cancer Center and UNC Gillings School of Global Public Health, among others. Its creation was inspired when a delegation from the base visited UNC-Chapel Hill in 2018 and met with UNC Lineberger’s Kurt M. Ribisl, PhD, a tobacco control policy expert and Jo Anne Earp Distinguished Professor and chair of the department of health behavior at UNC Gillings.
Ribisl, who had been part of a research group working on tobacco prevention and cessation in the U.S. Air Force, mentioned to the visiting delegation that most available data on soldiers’ tobacco use was from the Air Force, and that there was very little information pertaining to tobacco use in the Army. The group began to brainstorm about projects they could do together in North Carolina. That brainstorming discussion, along with some seed funding from the University Cancer Research Fund, led to partnership’s formation.
Each partner brings different ideas, strengths and potential funding sources to the group’s shared mission. What makes the partnership uniquely successful, though, is the structures and systems that have been put in place to effectively leverage the capabilities of all parties in a coordinated and continuous way, said Jennifer Green, PhD, MPH, Cumberland County’s health director.
“One of the reasons this partnership is so valuable is that it keeps us in a coordinated approach on work that is affiliated with the military,” said Green, a military spouse herself. “The team at Fort Liberty does a great job of highlighting the needs on base, and our community health assessments help our department identify needs in our county. Having UNC as an academic partner keeps us tied together, helping with data and research and thinking strategically about bringing in funding. We are driving all of that into something actionable, tangible and meaningful to the public.”
The partnership’s work focuses largely on cancer prevention, with projects aiming to increase rates of HPV vaccination and cancer screening among military members and to reduce the widespread use of tobacco on base.
Harnessing research findings to guide efforts
Research is a critical underpinning of this effort. Ribisl and Melissa A. Little, MPH, PhD, University of Virginia associate professor, who had worked together in the Air Force research group, continue to collaborate on tobacco research at Fort Liberty.
during a training program on the dangers of using tobacco and
nicotine products. Pearce said empowering individuals to support
tobacco cessation efforts is a force multiplier.
Quantitative surveys and focus groups help the partners better understand the frequency of tobacco use among soldiers as well as attitudes toward tobacco in the military community, which is important in designing interventions that will be effective in reducing tobacco use.
Studies show that tobacco use affects combat readiness by contributing to greater injury risk, poorer wound healing and worse night vision. Military personnel who use tobacco have worse physical and mental health and are at greater risk of early discharge compared to their non-smoking colleagues.
A 2021 community health assessment at Fort Liberty reported high levels of tobacco use on base, finding that more than 25% of the soldiers started using tobacco after they came to Fort Liberty. Annual surveys of the soldiers have since revealed a notable rise in vaping and oral nicotine pouches, such as Zyn, along with a feeling that tobacco use on base is socially acceptable and does not affect job performance.
“Almost 60% of service-member respondents reported current tobacco or vaping use. This increased to 75%, when looking at respondents that live in the barracks,” said Lt. Col. Teresa Pearce, MD, MPH, who recently retired as director of the Fort Liberty Department of Public Health.
With those survey results in mind and under Lt. Col. Pearce’s guidance, the partnership set the wheels in motion to implement and tailor the evidence-based Tobacco Treatment Specialist training program to meet the needs of the on-base providers and clinical staff.
In 2022, 50 Fort Liberty health care providers completed virtual Tobacco Treatment Specialist training; in 2023, 70 providers attended a two-day in-person training program. Now that providers have the information they need to confidently and proactively talk to their patients in the clinic about the harms of tobacco use, the next step is deploying a clinical system to steer patients toward cessation resources to help them quit.
With a large hospital and nine sizable clinics on base, this is no small task. “The base is like a big city,” said Hannah Prentice-Dunn, MPH, administrative director of UNC Lineberger’s Cancer Prevention and Control Program, who steers the day-to-day activities of the partnership and coordinates the partners’ work. “We are working together to determine what kind of clinical supports can be put into place to refer people for help if they want to quit, and what that quit system looks like for the patient.”
Additional cancer control and health initiatives
Another cancer control project that has seen initial success is an evidence-based intervention that increased participation in recommended HPV and cervical cancer screenings and HPV vaccination at Fort Liberty’s Robinson clinic, the largest clinic on post.
“HPV is the second most commonly diagnosed STI (sexually transmitted infection) for U.S. military members, and it’s the primary cause of cervical cancer and precancer,” said Kathryn Polaskey, MPH, an epidemiologist in the Fort Liberty Department of Public Health. “It also affects readiness. If someone has complications, or needs follow-up care or treatment, they are not deployable.”
Similar to the Tobacco Treatment Specialist training project, the partnership trained nursing staff at the EDC Clinic, one of Fort Liberty’s larger clinics on post, to recommend the HPV vaccine to soldiers during their routine care visits. A research team led by UNC Lineberger’s Melissa Gilkey, PhD, associate professor of health behavior at UNC Gillings, found that the nurse-led efforts to integrate HPV vaccination into routine care was effective in increasing awareness of the importance of HPV vaccines as cancer prevention. The partnership plans to conduct similar training at the base’s other clinics to further improve vaccination rates.
Screening rates are improving as well. Typically, the standard of care for outreach to patients who are overdue for a screening is to rely on clinic workers to place phone calls in their spare time. The partnership tested a pilot intervention consisting of four scheduled text reminders with specific messaging in each one. They found sending text messages was two times more effective than phone calls: 12.5% of patients receiving the typical phone calls booked a Pap smear, but 33% of patients who received the text message reminders booked their Pap smear.
“Not only did this project show that text messaging is an effective way to reach patients, but it was also a great opportunity to more generally include text innovations into what we do,” Polaskey said. “We talk a lot in public health about what the newest thing is, and how we’re moving away from pamphlets and trying to meet people where they are – and that’s websites, QR codes, and using your cell phones. If we remember that people use their phone like it’s a computer in their hand, it helps center what our public health work looks like moving forward.”
Another important finding was that a majority of patients had multiple contacts with health care providers, in several specialties, without any notes regarding overdue cancer screening. The partnership plans to develop a training component to ensure providers and clinic staff are taking every opportunity to remind patients of the health risks of missing screenings.
As they continue to work toward incorporating this text-based protocol as standard operating procedure, the public health partners hope to pilot a similar intervention strategy in other settings, such as colon cancer screening for the general population. The partnership will continue to work closely with Fort Liberty’s leadership to determine the requirements needed to adopt the intervention throughout the installation’s entire health network.
“We really look to our partners for what their public health and cancer prevention needs are and what they want to do, and we provide support to help make it happen,” Prentice-Dunn said. “It is so powerful to have all these groups from different sectors at the table, working together to make an impact.”
UNC students part of making a difference
UNC students also have a seat at the table. While students have been involved in the partnership for the past several years, UNC Gillings master’s students can now complete a practicum that allows them to work directly with partnership tobacco control and nutrition programs.
“This partnership provides a valuable training experience for our master’s students to get involved in a public health practice project where they can really make a difference,” Ribisl said.
Alana Austin, a UNC dual degree student pursuing a Master of Public Health and a Master of Social Work, began working with the partnership in the summer of 2023. As the partnership’s military health tobacco prevention and control research assistant, her responsibilities include conducting background research, drafting intervention materials, and occasionally developing partnership communications materials.
“A partnership like this one develops multifaceted students who will be prepared to function on any team in any interest area because of their exposure to working across organizations,” said Austin, who is from a military family and interned as a tobacco cessation counselor last year at the N.C. Basnight Cancer Hospital, UNC Lineberger’s clinical home. “Working with the partnership has allowed me to apply what I’m learning in class almost immediately.”
When the partnership expanded its focus from tobacco prevention and control to addressing food insecurity, nutrition students at UNC Gillings were a critical part of that effort. Past student Hannah Darr, MPH, for example, helped establish the Cumberland County Food Policy Council, and current doctoral student David Gaviria has played a lead role in establishing a WIC office on base.
“I firmly believe students bring a wealth of fresh insight and perspective to this partnership,” Austin said. “The students I have worked with on this partnership have injected a passion for the work that I believe propels it forward.”
Next steps for the partnership
As the partnership continues to grow and evolve, UNC will continue supporting the most critical public health needs highlighted by its partners on base and in surrounding areas. For Green, mental health and behavioral health, along with opioid use, are at the top of the priority list.
“We have an opportunity to step back and say, how does mental health and behavioral health impact public health?” she said. “Fort Liberty is a big piece of that because the Veterans Administration is here, soldiers have kids in the community, and youth suicide rates are up. This is the next big thing for us to be working on.”
There are also plans to expand this model beyond Fort Liberty and create a broader military population health initiative at UNC Lineberger to do cancer control work in other branches and installations throughout North Carolina. That expansion, Ribisl said, depends on whether additional funding can be secured to support a broader scope of work.
“Everyone wants our soldiers to be healthy – not just to be ready for active duty when they get the call, but also as they transition back to civilian life,” Ribisl said, noting that about 200,000 military personnel transition back to civilian life each year. “We really want to build on and expand this effort. We have a tiny budget, but this is one of the best things we are doing at Lineberger in terms of community outreach and working with public health partners. North Carolina is the nation’s most military-friendly state, and UNC is one of the top places in the country for doing cancer control work with the military.”